Dental Asia March/April 2022

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CLINICAL FEATURE implemented during the post-MA finishing phase for any additional A-P correction needed on U3 precision-cut hooks to L6 bonded buttons. Aside from the overbite correction, an overcorrection for individual tooth alignment such as rotations, was not built into the mandibular advancement aligners, as detailing the occlusion with additional aligners was to be done after the mandibular advancement phase is completed. The goal of the detailing aligners after the mandibular advancement phase was to improve individual tooth positions and the curve of Wilson around the bicuspids and the first molars. Class II elastics were worn for 10 weeks at night only, and then on the right side full time during the last two aligners in order to improve the midline. Bonded lingual retention was placed on upper 2-2 and lower 3-3. A clear upper retainer was delivered 1.5 months later, after the occlusion had settled. Final records post settling taken two months after the completion of treatment. No final radiographs were taken due to a lack of medical justification for these per Canada’s guidelines on dental radiographs permanent canines were located close to the desired position, a settling phase was started prior to a new intraoral scan being taken for the mandibular advancement phase. The goal of the mandibular advancement phase was to coordinate the arches and remove any anterior dental interferences preventing the posterior teeth from occluding in a solid Class I relationship. The precision wings were used to disclude the bite and position the mandible forward without needing elastics. Good aligner adaptation is especially important during this phase, so any added features that will reduce the plastic-to-tooth contact area such as button cutouts was avoided. Having two retentive attachments per quadrant was preferred during this phase, and lingual attachments** on the permanent first molars were used if the location of the precision wings prevented the placing of retention attachments buccally, which is our first choice. For retention, occlusallybeveled horizontal attachments which is 3 or 4mm depending on size of crown, were used. Avoid placing these attachments in the interproximal zones. By intruding the upper and lower incisors and using attachments on the canines and bicuspids to help anchor the aligners onto the teeth, the anterior interferences were removed. The arch widths were also optimised for a Class I bite during this phase, and anterior lingual precision bite ramps in the upper aligners helped generate intrusion forces in the anterior segments. At aligner #31 of 36 (MA phase), the patient had difficulty engaging the precision wings on the right side, so all the precision wings were cut off and the patient wore their aligners on 4-4 from stages 32 to 36. This allowed for passive eruption of the permanent first molars back into occlusion, as a common side effect seen with use of the precision wings, as well as other appliances with full-crown coverage like a Herbst, is disclusion of the posterior teeth. Rather than initiate a second mandibular advancement phase, Class II elastics were * Vivera retainers can be ordered with precision bite ramps as a feature. ** Since this case has been treated, lingual attachments have now become available and can be requested in special instructions in prescription form on molars or premolars for Invisalign treatment with mandibular advancement. One attachment per quadrant is recommended to provide sufficient retention. DA This article was published with Align Technology’s approval. References 1 Data on file at Align Technology, as of July 16, 2019. ABOUT THE AUTHOR Dr Bart Iwasiuk has been in private practice since 2002 and has treated patients with Invisalign aligners since his orthodontic residency training. He achieved Elite Provider status in 2012, and continues to push the limits of what can be accomplished with clear aligners. He received his DDS from the University of Toronto and his orthodontic certificate from the University of Rochester. 48 DENTAL ASIA MARCH / APRIL <strong>2022</strong>
USER REPORT Correcting a single midline diastema An ethical treatment plan; an impressive aesthetic result. By Dr Minesh Patel INITIAL PRESENTATION Mr MB is a long-standing patient with excellent oral health and a proven history of six-monthly examination and hygiene appointments with low caries, periodontal and tooth wear risk. After engaging in a discussion regarding the patient’s tooth position, he was delighted to hear that modern dentistry would allow closure of the gap between his front teeth (Fig. 1), without tooth damage and the need for orthodontics, which for him was too involved and time-consuming. Fig. 1 After discussing alternative options, including ceramic veneers, composite bonding was the most ethical option for this patient. When treating anterior teeth with any form of restorative dentistry, it is important to discuss tooth whitening to ensure the patient is aware that restorative materials, once selected, will match the existing tooth shade and cannot be altered in the future. Fig. 2 Fig. 3 ACTIVE CONCERNS Long-standing midline diastema, with scope for visual aesthetic improvement (Fig. 2). TREATMENT OBJECTIVE Minimally invasive aesthetic enhancement using home tooth whitening and correction of a single midline diastema using direct composite bonding with Coltene Brilliant EverGlow. TREATMENT PLAN 1. Four weeks of home tooth whitening using custom trays: • Two weeks 10% carbamide peroxide overnight use • Two weeks 16% carbamide peroxide overnight use 2. One week use of 6% hydrogen peroxide, for optional one-hour boosts 3. Fig. Two-week 3 review to allow for rebound and composite try-in 4. Freehand partial coverage, bonding UR1 molar and UL1 molar 5. Replacement upper “top up” whitening tray TREATMENT PROTOCOL To maximise the aesthetic gain planned Fig. 5 with composite bonding, it was agreed to complete a period of home tooth whitening to lift the base shade of all teeth which was currently close to an A2 (Fig. 3). Upper and lower good-quality alginates were taken and a period of four weeks’ home tooth whitening was performed, according to the aforementioned protocol. It is important to allow two weeks of no whitening, for the shade to settle and allow bond strengths to return to normal. At the review appointment, the patient and I were satisfied with the whitening progress. Shade BL was selected as the new and improved tooth colour, which was verified and accepted by the patient. A quick unbounded composite try-in was performed, using Coltene Brilliant EverGlow shade BL, while the teeth were at normal hydration to confirm the material selection. DENTAL ASIA MARCH / APRIL <strong>2022</strong> 49
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